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Medicaid: Tools for an Affordable Assisted Living Model

Medicaid: Tools for an Affordable Assisted Living Model. Robert L. Mollica Deputy Director. The trends. Medicaid coverage -- 21 states in 1996; 39 in September 2001 Use of Home and Community Based Waivers to cover services Participation growing - 60,000 in 2000

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Medicaid: Tools for an Affordable Assisted Living Model

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  1. Medicaid: Tools for an Affordable Assisted Living Model Robert L. Mollica Deputy Director

  2. The trends... • Medicaid coverage -- 21 states in 1996; 39 in September 2001 • Use of Home and Community Based Waivers to cover services • Participation growing - 60,000 in 2000 • Wide range of Medicaid rates • Cost comparison to nursing homes

  3. Medicaid coverage source WaiverAK KS ORAZ MD PACO MN RICT MS SDDE MT TXFL NE UTGA NV VT*HI NH WAIA NJ WIID* NMIL ND State Plan AR ME* MA MI* MO NY NC SC Planned/Activity AL CA DC IN LA OK TN (?) WY * State plan and waiver

  4. Medicaid coverage for assisted living

  5. The opportunities... • Expanding supply • Competition reducing occupancy rates • People exhausting assets • Regulations support aging-in-place • States seek more options for consumers, reduce nursing home spending

  6. The limitations... • Private demand still strong • Adequacy of rates • Higher level of service • Expectation of more government regulation

  7. Barriers to growth • Low rates in some states • Limited waiver slots, waiting lists • Some only serve residents spending down • Facilities may be reluctant to participate without guarantee of referrals • States concerned about quality due to staffing shortages • May be seen as HCBS failure or institutional

  8. The issues... • Market rates and level of care • Room and board allowance • Family supplementation • Aging-in-place • Medicaid eligibility ‘fast track’ decisions

  9. Public subsidy issues/options • SSI • Room and board only, or • Room and board and personal care services • Medicaid service options • Regular Medicaid state plan • 1915 (a) state plan amendment • Waiver approaches • HCBS Waiver - 1915 (c) • Managed care - 1115

  10. Medicaid state plan coverage • Cannot cover room and board • States cannot readily control spending • Entitlement program but can control provider type • Eligibility is based on need for a service • Available statewide - amount, scope, duration

  11. Medicaid waiver coverage • Cannot pay for room and board • No entitlement - can control spending • Can serve residents with income < $1590/month ($19,080 annual) • Services include meal preparation and serving costs • Must meet nursing home level of care • Waive amount, scope, duration

  12. Service and room & board • Some states include room and board paid by the resident in the rate • May be limited to SSI beneficiaries • Most cover Medicaid services only • R&B for SSI beneficiaries set by state policy • State SSI supplements may cover some personal care

  13. Cover R&B under Medicaid? • Requires change in Federal statute • Basis in nursing home reimbursement • Weakens non-institutional preference • Shifts costs from Federal SSI to states • SSI benefit: personal needs allowance only • Likelihood of raising rates????

  14. Illinois • Pilot project • New licensing law does not allow Medicaid payments in licensed facilities outside of pilot • Regional payments: $41.81 - $57.31per day (2000) • Room and board: $422 ($90 PNA) • Food stamps: $84

  15. Chicago $57.31 Northwest $48.42 West/central $43.43 Central $47.11 St. Louis region $47.36 South suburban $55.45 South $41.81 Regional rates/day (2000) Rate increases tied to average nursing home rate increase

  16. Oregon (2000) Level Service R&B Total 5 $1840.46 $441.70 $2282.16 4 $1490.76 $441.70 $1932.46 3 $1139.93 $441.70 $1581.63 2 $ 861.74 $441.70 $1303.44 1 $ 651.69 $441.70 $1093.39

  17. Oregon... Level Impairment 5 Depend in 4-6 ADLs or dependent in behavior & 1-2 other ADLs 4 1-2 ADLs or assistance in 4-6 ADLs + behavior 3 Assist w/4-6 ADLs or assist w/toileting, eating & behavior 2 Assist w/behavior AND eating or toileting 1 Assist in 2 critical ADLs or any 3 ADLs or assist w/1 critical and 1 other ADL

  18. Family supplementation • Allowed in 19 states • Prohibited in 7 states • No policy - 4 states • Considered unearned income for SSI • Should be paid to facility rather than beneficiary • Federal SSI benefit reduced one-third

  19. Serving the low income market … the future • Impact of Olmstead decision • States covering assisted living keeps growing but more slowly • High enrollment growth rates but still small totals • Rate variations likely to continue • Nursing homes relocation programs a priority

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